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Objective:To investigate the incidence and risk factors of human cytomegalovirus (HCMV) reactivation in immunocompetent severe pneumonia patients with mechanical ventilation and their effects on clinical outcomes.Methods:A prospective observational study was conducted. Forty-eight immunocompetent patients requiring invasive mechanical ventilation due to severe pneumonia in the department of critical care medicine of the First Affiliated Hospital of Guangzhou Medical University from June 30th, 2017 to July 1st, 2018 were enrolled. Meanwhile, all cases were followed up until 90 days after inclusion and were required to quantitatively detect HCMV DNA in serum at regular weekly intervals until 28 days after transferring to intensive care unit (ICU). Patients were divided into HCMV reactivation group (≥5×10 5 copies/L) and non-reactivation group (<5×10 5 copies/L) based on HCMV DNA at any time point within 28 days. Demographic data, basic indicators, respiratory indicators, disease severity scores, laboratory indicators, complication and clinical outcomes of the two groups were collected and analyzed. Multivariate Logistic regression analysis was performed to screen independent risk factors for HCMV reactivation. Results:All 48 subjects were tested positive for HCMV immunoglobulin G (IgG), so HCMV seropositive rate was 100%. HCMV reactivation occurred in 10 patients within 28 days after admission to ICU, and the reactivation incidence of HCMV was 20.83%. There was no significant difference in gender, age, body mass index (BMI), underling disease reasons for ICU transfer (except sepsis), basic vital signs, disease severity scores, or laboratory findings including infection, immune, blood routine, liver, kidney and circulatory indicators except neutrophils count (NEU), hypersensitivity C-reactive protein(hs-CRP), hemoglobin (Hb), blood urea nitrogen (BUN), N-terminal pro-brain natriuretic peptide (NT-proBNP) between the two groups. The height (cm: 160±6 vs. 166±8), body weight (kg: 49.4±11.2 vs. 57.6±10.5), Hb (g/L: 87±18 vs. 104±24) in HCMV reactivation group were significantly lower than non-reactivation group, as well as NEU [×10 9/L:12.7 (9.9, 22.5) vs. 8.9 (6.2, 13.8)], hs-CRP [mg/L: 115.5 (85.2, 136.6) vs. 39.9 (17.5, 130.2)], BUN [mmol/L:13.7 (8.9, 21.5) vs. 7.1 (4.9, 10.5)] and NT-proBNP [ng/L: 6 751 (2 222, 25 449) vs. 1 469 (419, 4 571)] within 24 hours of admission to ICU. The prevalence of sepsis [60.0% (6/10) vs. 15.8% (6/38)], blood transfusion [100.0% (10/10) vs. 60.5% (23/38)], hospitalization expense [ten thousand yuan: 35.7 (25.3, 67.1) vs. 15.2 (10.4, 22.0)], 90-day all-cause mortality [70.0% (7/10) vs. 21.1% (8/38)], length of ICU stay [days: 26 (16, 66) vs. 14 (9, 19)], the duration of mechanical ventilation [days: 26 (19, 66) vs. 13 (8, 18)] in HCMV reactivation group were significantly higher than non-reactivation group, and there were significant statistical differences between the two groups (all P < 0.05). Logistic regression analysis showed that sepsis was an independent risk factor for HCMV reactivation in immunocompetent mechanical ventilation severe pneumonia patients with mechanical ventilation [odds ratio ( OR) = 9.35, 95% confidence interval (95% CI) was 1.72-50.86, P = 0.010]. Conclusions:HCMV infection is very common in immunocompetent severe pneumonia patients on mechanical ventilation and incidence of HCMV reactivation is high. Moreover, HCMV reactivation could adversely affect clinical prognoses, and sepsis may be a risk factor for HCMV reactivation.
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To study the risk factors and the clinical characteristics of non-tuberculous mycobacterial (NTM) pulmonary diseases in patients with mechanical ventilation. Methods Retrospective survey was carried out in the patients with mechanical ventilation who combined with NTM pulmonary disease admitted to intensive care unit (ICU) of the First Affiliated Hospital of Guangzhou Medical University from May 2016 to May 2019. The general information, basic diseases, symptoms, signs, biochemical examinations, acid-fast stain test, mycobacterium culture and strain identification results, and chest CT data were collected to summarize the clinical characteristics of patients with mechanical ventilation combined with NTM pulmonary disease. Results There were 12 patients with mechanical ventilation combined with NTM pulmonary disease, 6 males and 6 females, 37-82 years old, with an average age of 65 years. In these 12 cases, patients with cancer (lung cancer were 4 cases, mediastinal tumor was 1 case) and after lung transplantation (use of anti-rejection drugs at the same time) were 5 and 2 respectively. Patients with at least 3 underlying diseases [included hypertension, diabetes, coronary heart disease, chronic obstructive pulmonary disease (COPD), bronchiectasis, chronic renal insufficiency] were 5. Clinical symptoms of the 12 cases were non-specific. The CT findings were not characteristic, including nodules, patchy infiltrations and fibrous streak. Pleural effusion was common among these subjects but nodular bronchiectatic patterns were absence. Routine laboratory indicators of bacterial infection were non-specific. But the number of lymphocytes of all cases decreased. Mycobacteria cultures were positive with the rapid growth of mycobacteria in these 12 cases. Mycobacterium avium (4 cases), Mycobacterium chelonae (4 cases), Mycobacterium chelonae-abscessus complex (2 cases) and Mycobacterium intracellulare (2 cases) were isolated. Anti-NTM therapy was given to the patients when the acid-fast staining test of their airway secretion was positive and the TB-DNA test was negative, including oral levofloxacin and clarithromycin. Finally, all patients were successfully weaned and discharged from ICU. Conclusions The clinical symptoms of NTM patients with pulmonary disease are non-specific, and the imaging features of chest CT are varied. Patients with mechanical ventilation in ICU, who have the risk of immune dysfunction or underlying structural lung diseases, and who have difficult controlled lung infection, accompanied by pleural effusion and with decreased lymphocytes, should be aware that pneumonia may be caused by non-tuberculous mycobacteria.
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Objective To investigate the high risk factors for pneumonia-related bloodstream infection (BSI) caused by Acinetobacter baumannii (AB) in ventilated patients. Methods A retrospective observation was conducted. The data of invasive-ventilated patients underwent AB pneumonia admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Disease from January 2011 to December 2015 were enrolled. The patients were divided into non-AB-BSI group and AB-BSI group. The following factors were evaluated including gender, age, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score at admission of intensive care unit (ICU), clinic pulmonary infection score (CPIS), underlying disease, neutropenia or agranulocytosis, hemoptysis, treatment of steroid or immunosuppressant in recent 3 months, central venous catheter (CVC), parenteral nutrition (PN), combined antibiotic therapy after the diagnose of AB pneumonia, duration of mechanical ventilation and the resistance of AB. The risk factors were analyzed by logistic regression analysis to confirm the independent high risk factors for the pneumonia-related BSI caused by AB in ventilated patients. Results 612 patients were enrolled, 561 patients in non-BSI group, and 51 in BSI group with 5-year BSI incidence of 8.3%. There was no significant difference in gender or age between the two groups. Compared with non-BSI group, the APACHE Ⅱ score (20.8±9.2 vs. 17.3±5.5) and CPIS (7.1±3.9 vs. 5.6±1.6) in BSI group were significantly increased (both P 6 [80.4% (41/51) vs. 28.0% (157/561)], chronic obstructive pulmonary diseases [COPD, 86.3% (44/51) vs. 46.7% (262/561)], diabetes mellitus [DM, 25.5% (13/51) vs. 14.8% (83/561)] in BSI group were more than patients in non-BSI group, the incidence of heart failure [HF, 5.9% (3/51) vs. 23.5% (132/561)] was significantly decreased, and the incidence of hemoptysis [27.4% (14/51) vs. 3.4% (19/561)], therapy of steroid or immunosuppressant [19.6% (10/51) vs. 7.8% (44/561)] and duration of mechanical ventilation > 14 days [80.4% (41/51) vs. 48.5% (272/561)] were significant increased (all P 6 [odds ratio (OR) = 2.513, 95% confidence interval (95%CI) = 1.400-20.439, P = 0.011], history of COPD (OR = 1.921, 95%CI = 0.068-5.603, P = 0.030), the treatment of steroid or immunosuppressant (OR = 2.012, 95%CI = 0.556-16.313, P = 0.021) and hemoptysis (OR = 1.866, 95%CI = 1.114-6.213, P = 0.037) were the independent risk factors for the pneumonia-related BSI caused by AB in ventilated patients. Conclusion CPIS > 6, history of COPD, the therapy of steroid or immunosuppressant and hemoptysis were the independent risk factors for the pneumonia-related BSI caused by AB in ventilated patients.
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Objective To investigate the value of N-terminal pro-B type natriuretic peptide (NT-proBNP) in predicting the outcome of spontaneous breathing trial (SBT) in ventilated elderly renal dysfunction patients. Methods The clinical data of patients who received mechanical ventilation in the Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Disease from January 2011 to December 2014 were analyzed retrospectively. AU the patients conformed to the following criteria: age > 65 years, endogenous creatinine clearance rate (CCr) 72 hours and undergone at least one SBT. The patients were assigned to a SBT success group and a SBT failure group according to the outcome of first SBT. The following factors were recorded: gender, age, the underlying disease [chronic obstructive pulmonary disease (COPD), heart failure (HF) and others], body mass index (BMI), serum pre-albumin (pre-ALB), and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, CCr and the concentration of the plasma NT-proBNP before SBT. Receiver operator characteristic curve (ROC) was plotted, and the predict value of NT-proBNP for the outcome of SBT in elder patients with kidney dysfunction was determined. Results A total of 58 patients with complete data were enrolled, with 41 cases in SBT success group, and 17 in SBT failure group. There were no significant differences in gender [male/female (cases): 26/15 vs. 13/4, χ2 = 0.930, P = 0.335], age (years: 70.2±7.4 vs. 74.6±10.1, t = 0.833, P = 0.339), the stratification of underlying diseases [COPD/HF/COPD+HF/others (cases): 15/9/13/4 vs. 7/3/5/2, χ2 = 0.242, P = 0.971], BMI (kg/m2: 25.2±11.3 vs. 27.4±6.43, t = 1.038, P = 0.221), pre-ALB (mg/L: 201.0±13.2 vs. 189.0±7.6, t = 0.688, P = 0.519), and APACHE Ⅱ score (12.2±3.2 vs. 13.5±6.3, t = 1.482, P = 0.147) and CCr (mL·min-1·1.73 m-2: 51.3±7.7 vs. 54.2±6.4, t = 0.711, P = 0.487) before SBT between SBT success group and SBT failure group. The concentration of plasma NT-proBNP in SBT failure group was significantly higher than that of the SBT success group (μg/L: 4.162±1.128 vs. 2.284±1.399, t = 4.905, P = 0.000). The area under ROC curve for plasma NT-proBNP in predicting successful SBT among elder patients with kidney dysfunction was 0.878, with 95% confidence interval (95%CI) 0.786 - 0.970. The cut-off method was used, and it was identified that the concentration of NT-proBNP < 3.350 μg/L as a predictor for successful SBT, with sensitivity of 82.4%, specificity of 87.8%, positive prediction value of 88.1% and negative predictive value of 76.5%. Conclusion The concentration of plasma NT-proBNP may increase in elderly kidney dysfunction patients undergoing ventilation, and NT-proBNP < 3.350 μg/L can serve as a good predictor for SBT success.
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Objective To investigate the effect of the modified spontaneous breathing trail (SBT) on the weaning procedure for elderly ventilated patients with chronic obstructive pulmonary disease (COPD). Methods Ventilated acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients ready for SBT from January 2013 to November 2014 were enrolled and were divided into 2-hour SBT (conventional SBT) group and 6-hour SBT (modified SBT) group randomly. The following factors were recorded and analyzed: age, gender, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ)score before SBT, mechanical ventilation time before SBT, the oxygenation index before SBT, rapid shallow breathing index (RSBI), maximum inspiratory pressure (MIP), the outcome of SBT and weaning, the ICU mortality and the length of stay in ICU. Results Forty-one cases were enrolled with 20 cases in 2-hour SBT group and 21 cases in 6-hour SBT group. Patients′age, gender, APACHE Ⅱ score before SBT, mechanical ventilation time before SBT, the oxygenation index before SBT, RSBI and MIP indicated no significant difference in two groups (P > 0.05). There was a significantly higher SBT successful rate (90.0%) in 2-hour SBT group than that in 6-hour SBT group (57.1%)(P = 0.018), but patients passing SBT successfully in 2-hour SBT group showed a significant lower weaning successful rate (72.2%) than those in 6-hour SBT group (100.0%)(P = 0.046). No significant difference was found in ICU morality and the length of stay in ICU in two groups (P > 0.05). Conclusions For elderly ventilated COPD patients , a modified SBT may serve as a useful procedure to predict weaning outcome which will increase the ICU mortality and the time of stay in ICU.
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ObjectiveTo explore the effect of prone position ventilation (PPV) on respiratory mechanics and prognosis in patients with acute respiratory distress syndrome (ARDS) concurrent with interstitial lung disease (ILD). Methods The data of 36 severe ARDS patients admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University from February 2013 to January 2015, were retrospectively analyzed. They were then divided into two groups according to the presence of ILD or not. The changes in respiratory mechanics and oxygenation indexes were compared before and after PPV treatment in all the patients. Kaplan-Meier method was applied to draw the 60-day survival curves of both groups.Results There were 17 cases with ILD among these 36 severe ARDS patients.① No significant difference was found in baseline data between ILD group and non-ILD group.② Respiratory mechanics and oxygenation pre-PPV and post-PPV: compared with pre-PPV, oxygenation index (PaO2/FiO2, mmHg, 1 mmHg = 0.133 kPa) post-PPV was significantly increased in both groups [ILD group : 132.0 (93.5, 172.0) vs. 118.7 (92.0, 147.8); non-ILD group: 126.1 (100.9, 170.0) vs. 109.2 (89.0, 135.0), bothP 0.05], and Crs was lower after PPV treatment in both groups, but without significant difference [non-ILD group: 22.7 (15.2, 27.1) vs. 24.3 (15.9, 48.9); ILD group: 16.2 (12.8, 25.6) vs. 18.9 (12.7, 27.3), bothP> 0.05].④ The 60-day mortality in ILD group was significantly higher than that in non-ILD group [88.2% (15/17) vs. 57.9% (11/19),P = 0.047). It was shown by Kaplan-Meier curves that 60-day survival patients in ILD group was significantly lower than those in non-ILD group (χ2 = 5.658,P = 0.017). Conclusions PPV can improve oxygenation in severe ARDS. Compared with non-ILD group, though the compliance of respiratory system in ILD group is increased during PPV, long-term effect is better in non-ILD group.
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Objective To investigate the effects of sepsis bundles in China.Method An observational study of 43 patients with severe pneumonia and septic shock admitted to the respiratory intertive care unit(1/11/2006-31/12/2007)was carried out.The selection criteria were in accordance with criteria set by International Conference On Sepsis in 2001.Implementation of 6 hours and 24 hours sepsis bundles was divided into 3 continu-ous phases consisting of education,trial,and application phase.A cohort of 43 patients with matched disease his-tory(1/1/2004-31/10/2006)was enrolled as control group.The percentages for categorical variables and mean±SD for continuous variables were reported.Chi-Square test.unpaired Student's t -test.paired-samples t test,univariate and multivariate logistic regression models were used.Statistical significance was defined as P＜0.05.Results There were very little significant differences in basic characteristics of patients between the two groups.Compared with control group,the differences in serrum lactate,fluid resuscitation and fluid volume infused within 6 hours and blood glucose control in shock subgroup were significant(P values were 0.024,0.009,0.045,and 0.000,respectively).Compared with control group,the differences in respiratory rate and oxygenation index of bundles group at 72 hours later were significant(P values were 0.033 and 0.041,respectively).Compared with control group,the differences in APACHE Ⅱ score and predicted mortality in shock subgroup of bundles were sig-nificant(P values were 0.017 and 0.040,respectively).Compared with control group,the reduction in absolute mortality was 23.30% in bundles group(P=0.019).Conclusions Implementation of sepsis bundles con-tributes noticeably to the significant reduction in mortality of patients with severe pneumonia and septic shock.